1
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Gooley S, Falk GL. Durability of radiofrequency ablation for long-segment and ultralong-segment Barrett's esophagus over 10 years. Surg Endosc 2024; 38:1239-1248. [PMID: 38092973 DOI: 10.1007/s00464-023-10608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/17/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Long-term durability data for radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in long-segment (LSBE) and ultralong-segment Barrett's esophagus (ULSBE) is lacking. This study aimed to determine 10-year cancer progression, eradication, and complication rates in LSBE and ULSBE patients treated with RFA. METHODS Single-surgeon prospective database of patients with LSBE (≥ 3 to < 8 cm) and ULSBE (≥ 8 cm) who underwent RFA (2001-2021) were retrospectively analyzed. Ten-year cancer progression calculated with Kaplan-Meier analysis. Eradication rates, including complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), and rates of recurrence and complications, compared between LSBE and ULSBE groups. RESULTS Ten years after starting treatment, the cancer rate was 14.3% in 56 patients. CR-D and CR-IM rates were 87.5% and 67.9%, respectively. Relapse rates from CR-D were 1.8% and 3.6% from CR-IM. Eradication rates for dysplasia in LSBE and ULSBE patients (90.6% versus 83.3%) and IM (71.9% versus 62.5%) were not significantly different. ULSBE patients required higher mean number of ablation sessions for IM eradication (4.7 versus 3.7, p = 0.032), while complication rates including strictures (4.2% versus 6.2%), perforation (0 versus 0), and bleeding (4.2% versus 3.1%), were similar between ULSBE and LSBE patients, respectively. On multivariate analysis, shorter Barrett's segment and baseline low-grade dysplasia were associated with increased likelihood for eradication of IM and dysplasia. A total number of ablation sessions or endoscopic resections ≥ 3 was associated with reduced likelihood for eradication. CONCLUSION RFA was durable in maintaining dysplasia and IM eradication in both LSBE and ULSBE over 10 years, and with low complication rates. IM eradication was more difficult to achieve in ULSBE. Late development of cancer occurred in 14.3%.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Doruk Seyfi
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Suzanna Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia.
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2
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Kim SE, Schlottmann F, Masrur MA. Management of Long-Segment Barrett's Esophagus. J Laparoendosc Adv Surg Tech A 2023; 33:1201-1210. [PMID: 37796531 DOI: 10.1089/lap.2023.0321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Background: Gastroesophageal reflux disease is a common gastrointestinal disorder with one of its most feared complications being Barrett's esophagus (BE). Currently, most of the recommendations of BE management are driven by the level of dysplasia. However, the length of BE might also be related to the risk of dysplasia/malignant transformation. We aimed to determine the appropriate management of BE based on its length. Materials and Methods: A systematic literature review was conducted with searches made on PubMed, Embase, and Cochrane databases. Long-segment BE (LSBE) was defined as 3 cm or longer and short-segment BE (SSBE) as under 3 cm. Studies evaluating the behavior and management of SSBE and/or LSBE were included for analysis. Results: LSBE have greater risk of dysplasia or progression to esophageal adenocarcinoma compared to SSBE. Despite this greater risk, LSBE and SSBE are currently managed similarly based on the presence and degree of dysplasia. Endoscopic and ablative techniques may have higher level of success and less complications in SSBE, compared to LSBE. Decreasing time interval between surveillance may be a viable option for managing LSBE. Conclusions: Although many algorithms of monitoring and treatment of BE remain the same regardless of segment length, current evidence suggests that more aggressive management for LSBE might be needed due to its higher risk of malignant progression.
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Affiliation(s)
- Sarah E Kim
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Francisco Schlottmann
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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3
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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4
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Wolfson P, Ho KMA, Wilson A, McBain H, Hogan A, Lipman G, Dunn J, Haidry R, Novelli M, Olivo A, Lovat LB. Endoscopic eradication therapy for Barrett's esophagus-related neoplasia: a final 10-year report from the UK National HALO Radiofrequency Ablation Registry. Gastrointest Endosc 2022; 96:223-233. [PMID: 35189088 DOI: 10.1016/j.gie.2022.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Long-term durability data for effectiveness of radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in patients with dysplastic Barrett's esophagus (BE) are lacking. METHODS We prospectively collected data from 2535 patients with BE (mean length, 5.2 cm; range, 1-20) and neoplasia (20% low-grade dysplasia, 54% high-grade dysplasia, 26% intramucosal carcinoma) who underwent RFA therapy across 28 UK hospitals. We assessed rates of invasive cancer and performed detailed analyses of 1175 patients to assess clearance rates of dysplasia (CR-D) and intestinal metaplasia (CR-IM) within 2 years of starting RFA therapy. We assessed relapses and rates of return to CR-D (CR-D2) and CR-IM (CR-IM2) after further therapy. CR-D and CR-IM were confirmed by an absence of dysplasia and intestinal metaplasia on biopsy samples taken at 2 consecutive endoscopies. RESULTS Ten years after starting treatment, the Kaplan-Meier (KM) cancer rate was 4.1% with a crude incidence rate of .52 per 100 patient-years. CR-D and CR-IM after 2 years of therapy were 88% and 62.6%, respectively. KM relapse rates were 5.9% from CR-D and 18.7% from CR-IM at 8 years, with most occurring in the first 2 years. Both were successfully retreated with rates of CR-D2 of 63.4% and CR-IM2 of 70.0% 2 years after retreatment. EMR before RFA increased the likelihood of rescue EMR from 17.2% to 41.7% but did not affect the rate of CR-D, whereas rescue EMR after RFA commenced reduced CR-D from 91.4% to 79.7% (χ2P < .001). CONCLUSIONS RFA treatment is effective and durable to prevent esophageal adenocarcinoma. Most treatment relapses occur early and can be successfully retreated.
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Affiliation(s)
- Paul Wolfson
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Kai Man Alexander Ho
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
| | - Ash Wilson
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Hazel McBain
- Gastrointestinal Services, University College London Hospital, London, UK
| | - Aine Hogan
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Gideon Lipman
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Jason Dunn
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
| | - Marco Novelli
- Research Department of Pathology, Cancer Institute, University College London Hospital, London, UK
| | - Alessandro Olivo
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK
| | - Laurence B Lovat
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
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5
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Genere JR, Visrodia K, Zakko L, Hoefnagel SJM, Wang KK. Spray cryotherapy versus continued radiofrequency ablation in persistent Barrett's esophagus. Dis Esophagus 2022; 35:6512102. [PMID: 35059707 DOI: 10.1093/dote/doab084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/09/2021] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation (RFA) is the first-line treatment for flat Barrett's esophagus (BE) with dysplasia, however its role for persistent Barrett's esophagus (PBE) is unclear. PBE requires additional RFA sessions or application of cryotherapy to improve therapeutic response. We performed a retrospective cohort study evaluating cases of PBE treated by endoscopic eradication programs, with and without spray cryotherapy, and evaluated their safety and efficacy. We retrospectively identified patients with PBE, defined as ≤50% BE reduction or unchanged dysplasia after at least two RFA sessions. PBE was treated either by continued RFA (RFA Group) or converting to spray cryotherapy (CRYO Group), both followed by surveillance period. The rate of adverse events (AE), complete response of intestinal metaplasia (CRIM) and complete response of dysplasia (CRD) were recorded. A total of 46 patients, 23 per group, underwent 622 endoscopic therapies. Circumferential BE length was longer in the CRYO Group, but other baseline characteristics were similar, including maximal BE length. Esophageal strictures accounted for 14/16 total AE, 71% of which were RFA related, compared with 14% related to spray cryotherapy (P = 0.02). Overall CRIM/CRD rates in CRYO (83%) and RFA (96%) groups were not statistically different (P = 0.16), however cases in the CRYO Group required more treatment encounters (Median 19 vs. 12, P ≤ 0.01). Multimodal endotherapy is effective for eradicating PBE. Treatment programs incorporating spray cryotherapy are associated with less esophageal strictures but may require more treatment sessions to achieve eradication.
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Affiliation(s)
- Juan Reyes Genere
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Kavel Visrodia
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Liam Zakko
- Connecticut Gastroenterology, Bristol, CT, USA
| | - Sanne J M Hoefnagel
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kenneth K Wang
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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6
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Desai M, Rösch T, Sundaram S, Chandrasekar VT, Kohli D, Spadaccini M, Hassan C, Repici A, Sharma P. Systematic review with meta-analysis: the long-term efficacy of Barrett's endoscopic therapy-stringent selection criteria and a proposal for definitions. Aliment Pharmacol Ther 2021; 54:222-233. [PMID: 34165205 DOI: 10.1111/apt.16473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/16/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Barrett's endoscopic therapy (BET) is well established for neoplasia in Barrett's oesophagus using a concept of complete eradication of all Barrett's. However, long-term efficacy is not known. AIMS To perform a systematic review and meta-analysis to examine long-term efficacy of BET for Barrett's neoplasia. METHODS Electronic databases were searched for studies meeting stringent criteria: (a) subjects with high-grade dysplasia and/or superficial adenocarcinoma who underwent BET (ablation ± endoscopic mucosal resection); (b) BET completion by confirmation of complete eradication of neoplasia (CE-N) and intestinal metaplasia (CE-IM) with systematic sampling and (c) clearly defined follow-up (endoscopy and biopsy) protocol of ≥2 years thereafter for detection of recurrence. Pooled estimates of CE-N and CE-IM after BET completion and follow-up were analysed. RESULTS Eight studies met the stringent criteria (n = 794, males 89%, age 64.6 years). Despite high efficacy of BET at therapy completion (CE-N: 95.9 [91.7-98.7]%; CE-IM: 90.9 [83-96.6]%), this declined (CE-N: 89 [73.4-98.2]%; CE-IM: 77.8 [65.6-88]%) over 3.4 years of follow-up. There was considerable heterogeneity. Only two studies reported a post-BET follow-up of >5 years (CE-IM 50 [41.5%-58.5]%). Higher person years of follow-up seem to correlate with decrease in BET efficacy. CONCLUSION Using stringent criteria for appropriate study selection with sufficient follow-up, a lack of high-quality controlled intervention trials becomes evident for assessment of long-term durable remission rates of BET despite initial high success rates. We plea for a uniform documentation of study details which could be used in future trials.
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Affiliation(s)
- Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.,Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Suneha Sundaram
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
| | | | - Divyanshoo Kohli
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.,Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
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7
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Farina DA, Condon A, Komanduri S, Muthusamy VR. A Practical Approach to Refractory and Recurrent Barrett's Esophagus. Gastrointest Endosc Clin N Am 2021; 31:183-203. [PMID: 33213795 DOI: 10.1016/j.giec.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy (EET) is recommended for patients with Barrett's esophagus (BE)-associated neoplasia and is effective in achieving complete eradication of intestinal metaplasia (CE-IM). However, BE that is refractory to EET, defined as partial or no improvement in dysplasia after less than or equal to 3 ablative sessions, and the development of recurrence post-EET is not uncommon. Identification of refractory BE or recurrent intestinal metaplasia should prompt esophageal physiologic testing and modification of antireflux strategy, as appropriate. In patients who ultimately fail standard EET despite optimization of reflux control, salvage EET with alternate modalities may need to be considered.
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Affiliation(s)
- Domenico A Farina
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - Ashwinee Condon
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA.
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8
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Garg S, Xie J, Inamdar S, Thomas SL, Trindade AJ. Spatial distribution of dysplasia in Barrett's esophagus segments before and after endoscopic ablation therapy: a meta-analysis. Endoscopy 2021; 53:6-14. [PMID: 32503057 DOI: 10.1055/a-1195-1000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dysplasia in Barrett's esophagus (BE) is focal and difficult to locate. The aim of this meta-analysis was to understand the spatial distribution of dysplasia in BE before and after endoscopic ablation therapy. METHODS A systematic search was performed of multiple databases to July 2019. The location of dysplasia prior to ablation was determined using a clock-face orientation (right or left half of the esophagus). The location of the dysplasia post-ablation was classified as within the tubular esophagus or at the top of the gastric folds (TGF). RESULTS 13 studies with 2234 patients were analyzed. Pooled analysis from six studies (819 lesions in 802 patients) showed that before ablation, dysplasia was more commonly located in the right half versus the left half (odds ratio [OR] 4.3; 95 % confidence interval [CI] 2.33 - 7.93; P < 0.001). Pooled analysis from seven studies showed that dysplasia after ablation recurred in 101 /1432 patients (7.05 %; 95 %CI 5.7 % - 8.4 %). Recurrence of dysplasia was located more commonly at the TGF (n = 68) than in the tubular esophagus (n = 34; OR 5.33; 95 %CI 1.75 - 16.21; P = 0.003). Of the esophageal lesions, 90 % (27 /30) were visible, whereas only 46 % (23 /50) of the recurrent dysplastic lesions at the TGF were visible (P < 0.001). CONCLUSION Before ablation, dysplasia in BE is found more frequently in the right half of the esophagus versus the left. Post-ablation recurrence is more commonly found in the TGF and is non-visible, compared with the tubular esophagus, which is mainly visible.
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Affiliation(s)
- Shashank Garg
- Division of Gastroenterology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jesse Xie
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sumant Inamdar
- Division of Gastroenterology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sheila L Thomas
- Education and Research Services, UAMS Library, Little Rock, Arkansas, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
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9
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Abstract
Because of the rising incidence and lethality of esophageal adenocarcinoma, Barrett's esophagus (BE) is an increasingly important premalignant target for cancer prevention. BE-associated neoplasia can be safely and effectively treated with endoscopic eradication therapy (EET), incorporating tissue resection and ablation. Because EET has proliferated, managing patients after complete eradication of intestinal metaplasia has taken on increasing importance. Recurrence after complete eradication of intestinal metaplasia occurs in 8%-10% of the patients yearly, and the incidence may remain constant over time. Most recurrences occur at the gastroesophageal junction, whereas those in the tubular esophagus are endoscopically visible and distally located. A simplified biopsy protocol limited to the distal aspect of the BE segment, in addition to gastroesophageal junction sampling, may enhance efficiency and cost without significantly reducing recurrence detection. Similarly, research suggests that current surveillance intervals may be excessively frequent, failing to reflect the cancer risk reduction of EET. If validated, longer surveillance intervals could reduce the burden of resource-intensive endoscopic surveillance. Several important questions in post-EET management remain unanswered, including surveillance duration, the significance of gastric cardia intestinal metaplasia, and the role of advanced imaging and nonendoscopic sampling techniques in detecting recurrence. These merit further research to enhance quality of care and promote a more evidence-based approach.
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Iwaya Y, Shimamura Y, Goda K, Rodríguez de Santiago E, Coneys JG, Mosko JD, Kandel G, Kortan P, May G, Marcon N, Teshima C. Clinical characteristics of young patients with early Barrett’s neoplasia. World J Gastroenterol 2019; 25:3069-3078. [PMID: 31293342 PMCID: PMC6603815 DOI: 10.3748/wjg.v25.i24.3069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/07/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal adenocarcinoma (EAC) and high-grade dysplasia (HGD) may appear in young patients with Barrett’s esophagus (BE). However, characteristics of Barrett’s-related neoplasia in this younger population remain unknown.
AIM To identify clinical characteristics that differ between young and old patients with early-stage Barrett’s-related neoplasia.
METHODS We conducted a retrospective analysis of a prospectively maintained database comprised of consecutive patients with early-stage EAC (pT1) and HGD at a tertiary-referral center between 2001 and 2017. Baseline characteristics, drug and risk factor exposures, clinicopathological staging of EAC/HGD and treatment outcomes [complete eradication of neoplasia (CE-N), complete eradication of intestinal metaplasia (CE-IM), recurrence of neoplasia and recurrence of intestinal metaplasia] were retrieved. Multivariate analyses were performed to identify factors that differed significantly between older and younger (≤ 50 years) patients.
RESULTS We identified 450 patients with T1 EAC and HGD (74% and 26%, respectively); 45 (10%) were ≤ 50 years. Compared to the older group, young patients were more likely to present with ongoing gastroesophageal reflux disease (GERD) symptoms (55% vs 38%, P = 0.04) and to be obese (body mass index > 30, 48% vs 32%, P = 0.04). Multivariate logistic regression analysis showed that young patients were significantly more likely to have ongoing GERD symptoms [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.04-3.85, P = 0.04] and to be obese (OR 2.06, 95%CI 1.07-3.98, P = 0.03) whereas the young group was less likely to have a smoking history (OR 0.39, 95%CI 0.20-0.75, P < 0.01) compared to the old group. However, there were no significant differences regarding tumor histology, CE-N, CE-IM, recurrence of neoplasia and recurrence of intestinal metaplasia (mean follow-up, 44.3 mo).
CONCLUSION While guidelines recommend BE screening in patients > 50 years of age, younger patients should be considered for screening endoscopy if they suffer from obesity and GERD symptoms.
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Affiliation(s)
- Yugo Iwaya
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Yuto Shimamura
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Kenichi Goda
- Department of Gastroenterology, Dokkyo Medical University, Tochigi 321-0293, Japan
| | | | - John Gerard Coneys
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Jeffrey D Mosko
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Gabor Kandel
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Paul Kortan
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Gary May
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Norman Marcon
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Christopher Teshima
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
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11
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Persistent intestinal metaplasia after endoscopic eradication therapy of neoplastic Barrett's esophagus increases the risk of dysplasia recurrence: meta-analysis. Gastrointest Endosc 2019; 89:913-925.e6. [PMID: 30529044 DOI: 10.1016/j.gie.2018.11.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic eradication therapy (EET) is the main treatment for dysplastic Barrett's esophagus and intramucosal adenocarcinoma. Although the goal of EET is to achieve complete remission of intestinal metaplasia (CRIM), treatment might achieve complete remission of dysplasia (CR-D) only, without achieving CRIM. Persistent intestinal metaplasia after eradication of dysplasia might carry a higher risk for progression into advanced neoplasia. METHODS We performed a systematic review and meta-analysis after searching multiple databases to identify studies that evaluated dysplasia recurrence risk after successful eradication of neoplasia with EET. We calculated the pooled cumulative incidence of dysplasia and advanced neoplasia recurrence after CRIM and CR-D only and then compared the two using risk ratios. RESULTS Forty studies were included (4410 patients with total follow-up of 12,976 patient-years). A total of 4061 achieved CRIM and 349 achieved CR-D only. The cumulative incidence of CR-D only was 14% (95% confidence interval [CI], 10%-19%). The pooled cumulative incidence of any dysplasia recurrence after achieving CRIM was 5% (95% CI, 3%-7%) and 12% (95% CI, 4%-23%) after achieving CR-D only. Comparing dysplasia detection after achieving CR-D only with CRIM, there was a significantly higher risk for detection after CR-D (risk ratio [RR], 2.8; 95% CI, 1.7-4.6). The pooled cumulative incidence rate of high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) recurrence was 3% (95% CI, 2%-4%) after achieving CRIM and 6% (95% CI, 0%-16%) after achieving CR-D only. Comparing HGD/EAC recurrence after achieving CR-D only with CRIM, there was a significantly higher risk for recurrence after CR-D (RR, 3.6; 95% CI, 1.45-9). When excluding patients who underwent ablation for non-dysplastic Barrett's esophagus only, these differences persisted with dysplasia recurrence after achieving CR-D only compared with CRIM showing a significantly higher risk for recurrence after CR-D (RR, 2.9; 95% CI, 1.66-5). CONCLUSIONS CRIM was associated with a lower risk of dysplasia and advanced neoplasia recurrence compared with CR-D only. Achieving CRIM should remain the goal of EET in dysplastic Barrett's esophagus.
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12
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Cotton CC, Haidry R, Thrift AP, Lovat L, Shaheen NJ. Development of Evidence-Based Surveillance Intervals After Radiofrequency Ablation of Barrett's Esophagus. Gastroenterology 2018; 155:316-326.e6. [PMID: 29655833 PMCID: PMC6067977 DOI: 10.1053/j.gastro.2018.04.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/19/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) recurs in 25% or more of patients treated successfully with radiofrequency ablation (RFA), so surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CEIM). The frequency of surveillance is informed only by expert opinion. We aimed to model the incidence of neoplastic recurrence, validate the model in an independent cohort, and propose evidence-based surveillance intervals. METHODS We collected data from the United States Radiofrequency Ablation Registry (US RFA, 2004-2013) and the United Kingdom National Halo Registry (UK NHR, 2007-2015) to build and validate models to predict the incidence of neoplasia recurrence after initially successful RFA. We developed 3 categories of risk and modeled intervals to yield 0.1% risk of recurrence with invasive adenocarcinoma. We fit Cox proportional hazards models assessing discrimination by C statistic and 95% confidence limits. RESULTS The incidence of neoplastic recurrence was associated with most severe histologic grade before CEIM, age, endoscopic mucosal resection, sex, and baseline BE segment length. In multivariate analysis, a model based solely on most severe pre-CEIM histology predicted neoplastic recurrence with a C statistic of 0.892 (95% confidence limit, 0.863-0.921) in the US RFA registry. This model also performed well when we used data from the UK NHR. Our model divided patients into 3 risk groups based on baseline histologic grade: non-dysplastic BE; indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia; or intramucosal adenocarcinoma. For patients with low-grade dysplasia, we propose surveillance endoscopy at 1 and 3 years after CEIM; for patients with high-grade dysplasia or intramucosal adenocarcinoma, we propose surveillance endoscopy at 0.25, 0.5, and 1 year after CEIM, then annually. CONCLUSION In analyses of data from the US RFA and UK NHR for BE, a much-attenuated schedule of surveillance endoscopy would provide protection from invasive adenocarcinoma. Adherence to the recommended surveillance intervals could decrease the number of endoscopies performed yet identify unresectable cancers at rates less than 1/1000 endoscopies.
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Affiliation(s)
- Cary C Cotton
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, NC, USA
| | - Rehan Haidry
- University College Hospital, Department of Gastroenterology, Fitzrovia, London, UK,Division of Surgery & Interventional Science, University College London, London, UK
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA,Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Laurence Lovat
- University College Hospital, Department of Gastroenterology, Fitzrovia, London, UK,Division of Surgery & Interventional Science, University College London, London, UK
| | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina.
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13
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Higher Rate of Barrett's Detection in the First Year After Successful Endoscopic Therapy: Meta-analysis. Am J Gastroenterol 2018; 113:959-971. [PMID: 29899439 DOI: 10.1038/s41395-018-0090-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic eradication therapy (EET) is highly effective in treating dysplastic Barrett's esophagus (BE). Current surveillance intervals after complete remission of intestinal metaplasia (CRIM) are based on expert opinion. We performed a meta-analysis to compare BE detection in the first year to the subsequent ones METHODS: We searched MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials through 1 August 2017 for studies reporting IM and neoplasia detection after CRIM. Pooled incidence rate (IR) of IM detection was calculated for each year after CRIM. We compared IM, dysplasia, and high grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) detection in the first year after CRIM to the years after. RESULTS Twenty two studies were included involving 1973 patients with follow-up of 5176 patient-years. IM detection IR per patient-year in the 1st year was 12% (95% CI: 8-17%), in the 2nd year 7% (95% CI: 4-11%), and in the 3rd year 3% (95% CI: 1-7%). IM detection rate in the first year was significantly higher compared to the years after (relative risk (RR) 1.8 (95% CI: 1.29-2.49)). Dysplasia detection IR in the first year after achieving CRIM was 3% per patient-year (95% CI: 2-5%). Dysplasia detection IR after the first year was 1% (95% CI: 1-2%) and significantly higher in the first year compared to the years after (RR: 1.92 (95% CI: 1.32-2.8). HGD/EAC detection was 1 %/patient-year (95% CI: 0-2%) in the first year after CRIM compared to 0%/patient-year (95% CI: 0-1%) in subsequent years. HGD/EAC IR was higher in the first year (RR: 1.58 (95% CI: 0.94-2.65)). CONCLUSION Neoplasia detection after successful treatment of BE appears more common within the first year of surveillance. This appears to be due to incompletely treated prevalent rather than recurrent disease. More intensive surveillance in the first year following CRIM is warranted.
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14
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Visrodia K, Zakko L, Singh S, Leggett CL, Iyer PG, Wang KK. Cryotherapy for persistent Barrett's esophagus after radiofrequency ablation: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87:1396-1404.e1. [PMID: 29476849 PMCID: PMC6557401 DOI: 10.1016/j.gie.2018.02.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A small but significant proportion of patients with Barrett's esophagus (BE) have persistent dysplasia or intestinal metaplasia (IM) after treatment with radiofrequency ablation (RFA). Cryotherapy is a cold-based ablative modality that is increasingly being used in this setting. We aimed to better understand the efficacy of second-line cryotherapy in patients with BE who have persistent dysplasia or IM after RFA by conducting a systematic review and meta-analysis. METHODS We performed a systematic literature search of Pubmed, EMBASE, and Web of Science through September 1, 2017. Articles were included for meta-analysis based on the following inclusion criteria: ≥5 patients with BE treated with RFA had persistent dysplasia or IM; they subsequently underwent ≥1 session of cryotherapy with follow-up endoscopy; the proportions of patients achieving complete eradication of dysplasia (CE-D) and/or IM (CE-IM) were reported. The main outcomes were pooled proportions of CE-D and CE-IM by using a random effects model. RESULTS Eleven studies making up 148 patients with BE treated with cryotherapy for persistent dysplasia or IM after RFA were included. The pooled proportion of CE-D was 76.0% (95% confidence interval [CI] 57.7-88.0), with substantial heterogeneity (I2 = 62%). The pooled proportion of CE-IM was 45.9% (95% CI, 32.0-60.5) with moderate heterogeneity (I2 = 57%). Multiple preplanned subgroup analyses did not sufficiently explain the heterogeneity. Adverse effects were reported in 6.7% of patients. CONCLUSION Cryotherapy successfully achieved CE-D in three fourths and CE-IM in half of patients with BE who did not respond to initial RFA. Considering its favorable safety profile, cryotherapy may be a viable second-line option for this therapeutically challenging cohort of patients with BE, but higher-quality studies validating this remain warranted.
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Affiliation(s)
- Kavel Visrodia
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Liam Zakko
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Singh
- Division of Gastroenterology, University of California
San Diego, La Jolla, California
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Care of the Postablation Patient: Surveillance, Acid Suppression, and Treatment of Recurrence. Gastrointest Endosc Clin N Am 2017; 27:515-529. [PMID: 28577772 DOI: 10.1016/j.giec.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy is effective and durable for the treatment of Barrett's esophagus (BE), with low rates of recurrence of dysplasia but significant rates of recurrence of intestinal metaplasia. Identified risk factors for recurrence include age and length of BE before treatment and may also include presence of a large hiatal hernia, higher grade of dysplasia before treatment, and history of smoking. Current guidelines for surveillance following ablation are limited, with recommendations based on low-quality evidence and expert opinion. New modalities including optical coherence tomography and wide-area tissue sampling with computer-assisted analysis show promise as adjunctive surveillance modalities.
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16
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Fujii-Lau LL, Cinnor B, Shaheen N, Gaddam S, Komanduri S, Muthusamy VR, Das A, Wilson R, Simon VC, Kushnir V, Mullady D, Edmundowicz SA, Early DS, Wani S. Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis. Endosc Int Open 2017; 5:E430-E449. [PMID: 28573176 PMCID: PMC5451278 DOI: 10.1055/s-0043-106578] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett's esophagus (BE) patients. AIM (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. METHODS A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. RESULTS A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 - 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 - 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 - 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 - 10.5)/100 PY vs. 5.1 (3.1 - 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 - 7.3)/100 PY vs. 3.1 (1.7 - 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). CONCLUSION The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.
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Affiliation(s)
| | - Birtukan Cinnor
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, MO, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | | | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ, USA
| | - Robert Wilson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Daniel Mullady
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dayna S. Early
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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17
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Komanduri S, Kahrilas PJ, Krishnan K, McGorisk T, Bidari K, Grande D, Keefer L, Pandolfino J. Recurrence of Barrett's Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control. Am J Gastroenterol 2017; 112:556-566. [PMID: 28195178 DOI: 10.1038/ajg.2017.13] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Recent data suggest that effective control of gastroesophageal reflux improves outcomes associated with endoscopic eradication therapy (EET) for Barrett's esophagus (BE). However, the impact of reflux control on preventing recurrent intestinal metaplasia and/or dysplasia is unclear. The aims of the study were: (a) to determine the effectiveness and durability of EET under a structured reflux management protocol and (b) to determine the impact of optimizing anti-reflux therapy on achieving complete eradication of intestinal metaplasia (CE-IM). METHODS Consecutive BE patients referred for EET were enrolled and managed with a standardized reflux management protocol including twice-daily PPI therapy during eradication. Primary outcomes were rates of CE-IM and IM or dysplasia recurrence. RESULTS Out of 221 patients enrolled (46.0% with high-grade dysplasia/intramucosal carcinoma, 34.0% with low-grade dysplasia, and 20.0% with non-dysplastic BE) an overall CE-IM of 93% was achieved within 11.6±10.2 months. Forty-eight patients did not achieve CE-IM in 3 sessions. After modification of their reflux management, 45 (93.7%) achieved CE-IM in a mean of 1.1 RFA sessions. Recurrence occurred in 13 patients (IM in 10(4.8%), dysplasia in 3 (1.5%)) during a mean follow-up of 44±18.5 months. The only significant predictor of recurrence was the presence of a hiatal hernia. Recurrence of IM was significantly lower than historical controls (10.9 vs. 4.8%, P=0.04). CONCLUSIONS The current study highlights the importance of reflux control in patients with BE undergoing EET. In this setting, EET has long-term durability with low recurrence rates providing early evidence for extending endoscopic surveillance intervals after EET.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kumar Krishnan
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tim McGorisk
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kiran Bidari
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David Grande
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Laurie Keefer
- Ichan School of Medicine at Mount Sinai, New York, New York, USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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18
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Outcomes of Radiofrequency Ablation for Dysplastic Barrett's Esophagus: A Comprehensive Review. Gastroenterol Res Pract 2016; 2016:4249510. [PMID: 28070182 PMCID: PMC5192328 DOI: 10.1155/2016/4249510] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/24/2016] [Indexed: 12/14/2022] Open
Abstract
Barrett's esophagus is a condition in which the normal squamous lining of the esophagus has been replaced by columnar epithelium containing intestinal metaplasia induced by recurrent mucosal injury related to gastroesophageal reflux disease. Barrett's esophagus is a premalignant condition that can progress through a dysplasia-carcinoma sequence to esophageal adenocarcinoma. Multiple endoscopic ablative techniques have been developed with the goal of eradicating Barrett's esophagus and preventing neoplastic progression to esophageal adenocarcinoma. For patients with high-grade dysplasia or intramucosal neoplasia, radiofrequency ablation with or without endoscopic resection for visible lesions is currently the most effective and safe treatment available. Recent data demonstrate that, in patients with Barrett's esophagus and low-grade dysplasia confirmed by a second pathologist, ablative therapy results in a statistically significant reduction in progression to high-grade dysplasia and esophageal adenocarcinoma. Treatment of dysplastic Barrett's esophagus with radiofrequency ablation results in complete eradication of both dysplasia and of intestinal metaplasia in a high proportion of patients with a low incidence of adverse events. A high proportion of treated patients maintain the neosquamous epithelium after successful treatment without recurrence of intestinal metaplasia. Following successful endoscopic treatment, endoscopic surveillance should be continued to detect any recurrent intestinal metaplasia and/or dysplasia. This paper reviews all relevant publications on the endoscopic management of Barrett's esophagus using radiofrequency ablation.
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19
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Qumseya BJ, Wani S, Desai M, Qumseya A, Bain P, Sharma P, Wolfsen H. Adverse Events After Radiofrequency Ablation in Patients With Barrett's Esophagus: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:1086-1095.e6. [PMID: 27068041 DOI: 10.1016/j.cgh.2016.04.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/29/2016] [Accepted: 04/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) is routinely used for treatment of Barrett's esophagus with dysplasia. Despite the relative safety of this method, there have been imprecise estimates of the rate of adverse events. We performed a systematic review and meta-analysis to assess the rate of adverse events associated with RFA with and without EMR. METHODS We searched MEDLINE, Embase, Web of Science, and Cochrane Central through October 22, 2014. The primary outcome of interest was the overall rate of adverse events after RFA with or without EMR. We used forest plots to contrast effect sizes among studies. RESULTS Of 1521 articles assessed, 37 met our inclusion criteria (comprising 9200 patients). The pooled rate of all adverse events from RFA with or without EMR was 8.8% (95% confidence interval [CI], 6.5%-11.9%); 5.6% of patients developed strictures (95% CI, 4.2%-7.4%), 1% had bleeding (95% CI, 0.8%-1.3%), and 0.6% developed a perforation (95% CI, 0.4%-0.9%). In studies that compared RFA with vs without EMR, the relative risk for adverse events was significantly higher for RFA with EMR (4.4) (P = .015). There was a trend toward higher proportions of adverse events in prospective studies compared with retrospective studies (11.3% vs 7.8%, P = .20). Other factors associated with adverse events included Barrett's esophagus and length and baseline histology. CONCLUSIONS In a systematic review and meta-analysis, we found the relative risk for adverse events from RFA to be about 4-fold higher with EMR than without; we identified factors associated with these events. Endoscopists should discuss these risks with patients before endoscopic eradication therapy.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Madhav Desai
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Amira Qumseya
- Department of Biostatistics, Florida State University, Tallahassee, Florida
| | - Paul Bain
- Harvard School of Public Health, Boston, Massachusetts
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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Li N, Pasricha S, Bulsiewicz WJ, Pruitt RE, Komanduri S, Wolfsen HC, Chmielewski GW, Corbett FS, Chang KJ, Shaheen NJ. Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett's esophagus: results from the United States Radiofrequency Ablation Registry. Dis Esophagus 2016; 29:537-43. [PMID: 26121935 PMCID: PMC4977202 DOI: 10.1111/dote.12386] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effects of preceding endoscopic mucosal resection (EMR) on the efficacy and safety of radiofrequency ablation (RFA) for treatment of nodular Barrett's esophagus (BE) is poorly understood. Prior studies have been limited to case series from individual tertiary care centers. We report the results of a large, multicenter registry. We assessed the effects of preceding EMR on the efficacy and safety of RFA for nodular BE with advanced neoplasia (high-grade dysplasia or intramucosal carcinoma) using the US RFA Registry, a nationwide study of BE patients treated with RFA at 148 institutions. Safety outcomes included stricture, gastrointestinal bleeding, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia (CEIM), complete eradication of dysplasia (CED), and number of RFA treatments needed to achieve CEIM. Analyses comparing patients with EMR before RFA to patients undergoing RFA alone were performed with Student's t-test, Chi-square test, logistic regression, and Kaplan-Meier analysis. Four hundred six patients were treated with EMR before RFA for nodular BE, and 857 patients were treated with RFA only for non-nodular BE. The total complication rates were 8.4% in the EMR-before-RFA group and 7.2% in the RFA-only group (P = 0.48). Rates of stricture, bleeding, and hospitalization were not significantly different between patients treated with EMR before RFA and patients treated with RFA alone. CEIM was achieved in 84% of patients treated with EMR before RFA, and 84% of patients treated with RFA only (P = 0.96). CED was achieved in 94% and 92% of patients in EMR-before-RFA and RFA-only group, respectively (P = 0.17). Durability of eradication did not differ between the groups. EMR-before-RFA for nodular BE with advanced neoplasia is effective and safe. The preceding EMR neither diminished the efficacy nor increased complication rate of RFA treatment compared to patients with advanced neoplasia who had RFA with no preceding EMR. Preceding EMR is not associated with poorer outcomes in RFA.
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Affiliation(s)
- N. Li
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - S. Pasricha
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - W. J. Bulsiewicz
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - R. E. Pruitt
- Nashville Gastrointestinal Specialists, Nashville, Tennessee
| | - S. Komanduri
- Northwestern University School of Medicine, Chicago, Illinois
| | | | | | - F. S. Corbett
- Gastroenterology Associates of Sarasota, Sarasota, Florida
| | - K. J. Chang
- University of California at Irvine, Orange, California, USA
| | - N. J. Shaheen
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Krishnamoorthi R, Singh S, Ragunathan K, Katzka DA, Wang KK, Iyer PG. Risk of recurrence of Barrett's esophagus after successful endoscopic therapy. Gastrointest Endosc 2016; 83:1090-1106.e3. [PMID: 26902843 PMCID: PMC4937826 DOI: 10.1016/j.gie.2016.02.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Previous estimates of incidence of intestinal metaplasia (IM) recurrence after achieving complete remission of IM (CRIM) through endoscopic therapy of Barrett's esophagus (BE) have varied widely. We performed a systematic review and meta-analysis of studies to estimate an accurate recurrence risk after CRIM. METHODS We performed a systematic search of multiple literature databases through June 2015 to identify studies reporting long-term follow-up after achieving CRIM through endoscopic therapy. Pooled incidence rate (IR) of recurrent IM, dysplastic BE, and high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) per person-year of follow-up after CRIM was estimated. Factors associated with recurrence were also assessed. RESULTS We identified 41 studies that reported 795 cases of recurrence in 4443 patients over 10,427 patient-years of follow-up. This included 21 radiofrequency ablation studies that reported 603 cases of IM recurrence in 3186 patients over 5741 patient-years of follow-up. Pooled IRs of recurrent IM, dysplastic BE, and HGD/EAC after radiofrequency ablation were 9.5% (95% CI, 6.7-12.3), 2.0% (95% CI, 1.3-2.7), and 1.2% (95% CI, .8-1.6) per patient-year, respectively. When all endoscopic modalities were included, pooled IRs of recurrent IM, dysplastic BE, and HGD/EAC were 7.1% (95% CI, 5.6-8.6), 1.3% (95% CI, .8-1.7), and .8% (95% CI, .5-1.1) per patient-year, respectively. Substantial heterogeneity was noted. Increasing age and BE length were predictive of recurrence; 97% of recurrences were treated endoscopically. CONCLUSIONS The incidence of recurrence after achieving CRIM through endoscopic therapy was substantial. A small minority of recurrences were dysplastic BE and HGD/EAC. Hence, continued surveillance after CRIM is imperative. Additional studies with long-term follow-up are needed.
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Affiliation(s)
- Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karthik Ragunathan
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Martinucci I, de Bortoli N, Russo S, Bertani L, Furnari M, Mokrowiecka A, Malecka-Panas E, Savarino V, Savarino E, Marchi S. Barrett’s esophagus in 2016: From pathophysiology to treatment. World J Gastrointest Pharmacol Ther 2016; 7:190-206. [PMID: 27158534 PMCID: PMC4848241 DOI: 10.4292/wjgpt.v7.i2.190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/05/2015] [Accepted: 03/18/2016] [Indexed: 02/06/2023] Open
Abstract
Esophageal complications caused by gastroesophageal reflux disease (GERD) include reflux esophagitis and Barrett’s esophagus (BE). BE is a premalignant condition with an increased risk of developing esophageal adenocarcinoma (EAC). The carcinogenic sequence may progress through several steps, from normal esophageal mucosa through BE to EAC. A recent advent of functional esophageal testing (particularly multichannel intraluminal impedance and pH monitoring) has helped to improve our knowledge about GERD pathophysiology, including its complications. Those findings (when properly confirmed) might help to predict BE neoplastic progression. Over the last few decades, the incidence of EAC has continued to rise in Western populations. However, only a minority of BE patients develop EAC, opening the debate regarding the cost-effectiveness of current screening/surveillance strategies. Thus, major efforts in clinical and research practice are focused on new methods for optimal risk assessment that can stratify BE patients at low or high risk of developing EAC, which should improve the cost effectiveness of screening/surveillance programs and consequently significantly affect health-care costs. Furthermore, the area of BE therapeutic management is rapidly evolving. Endoscopic eradication therapies have been shown to be effective, and new therapeutic options for BE and EAC have emerged. The aim of the present review article is to highlight the status of screening/surveillance programs and the current progress of BE therapy. Moreover, we discuss the recent introduction of novel esophageal pathophysiological exams that have improved the knowledge of the mechanisms linking GERD to BE.
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Predictors Of Treatment Failure After Radiofrequency Ablation For Intramucosal Adenocarcinoma in Barrett Esophagus. Am J Surg Pathol 2016; 40:554-62. [DOI: 10.1097/pas.0000000000000566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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David WJ, Qumseya BJ, Qumsiyeh Y, Heckman MG, Diehl NN, Wallace MB, Raimondo M, Woodward TA, Wolfsen HC. Comparison of endoscopic treatment modalities for Barrett's neoplasia. Gastrointest Endosc 2015; 82:793-803.e3. [PMID: 26071064 DOI: 10.1016/j.gie.2015.03.1979] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/27/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND There are few data comparing endoscopic treatment outcomes for Barrett's esophagus (BE). OBJECTIVE To compare treatment outcomes in BE patients treated with radiofrequency ablation (RFA), RFA after EMR, and porfimer sodium photodynamic therapy (Ps-PDT). DESIGN Retrospective, observational study. SETTING Single tertiary center between 2001 and 2013. PATIENTS A total of 342 BE patients treated with RFA (n = 119), EMR+RFA (n = 98), and Ps-PDT (n = 125). MAIN OUTCOME MEASUREMENTS Rates of complete remission of intestinal metaplasia (CRIM), BE recurrence, and adverse events. RESULTS Baseline BE high-grade dysplasia (HGD) and adenocarcinoma were more common in the Ps-PDT group (89%) compared with the EMR-RFA (70%) and RFA (37%) groups. At a median follow-up of 14.2 months, 173 patients (50.6%) achieved CRIM. CRIM was significantly more common in Ps-PDT patients compared with RFA (P < .001) and EMR-RFA (P < .001) patients on multivariable analysis. In patients who achieved CRIM, the rates of subsequent BE recurrence were relatively similar among the 3 groups. Although the rates of bleeding were similar, strictures were less common in RFA patients (2.4%) compared with EMR-RFA (13.3%, P = .001) and Ps-PDT (10.4%, P =.043) patients. CONCLUSION This study of endoscopic treatment for Barrett's dysplasia and neoplasia found that complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT. Further studies are required to determine which ablation and resection techniques are ideally suited for each BE patient.
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Affiliation(s)
- Waseem J David
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Florida State University, Archbold Medical Group, Thomasville, Georgia, USA
| | - Yazen Qumsiyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Brown J, Alsop B, Gupta N, Buckles DC, Olyaee MS, Vennalaganti P, Kanakadandi VN, Saligram S, Sharma P. Effectiveness of focal vs. balloon radiofrequency ablation devices in the treatment of Barrett's esophagus. United European Gastroenterol J 2015; 4:236-41. [PMID: 27087952 DOI: 10.1177/2050640615594549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/09/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIMS The safety and efficacy of radiofrequency ablation (RFA) in treatment of Barrett's esophagus (BE)-associated dysplasia has been well established. The effectiveness of focal and balloon RFA devices has not been compared. Therefore, the aim of our study was to assess the effectiveness of focal and balloon RFA devices in the treatment of BE by calculating absolute and percentage change in BE length with RFA therapy by comparing pre- and post-treatment BE length. PATIENTS AND METHODS This is a retrospective cross-sectional study of patients who underwent at least one treatment with either focal and/or balloon RFA devices who were identified from two tertiary centers. Patients' demographics, hiatal hernia, pre- and post-treatment BE length, prior use of endoscopic therapies and number of sessions were recorded. RESULTS Sixty-one patients who had undergone 161 RFA treatment sessions met inclusion criteria. There was no significant difference in percentage change in BE length with greater number of RFA sessions. RFA with a focal device resulted in greater percentage reduction in BE length compared to the balloon system (73% vs. 39%, p < 0.01). After adjusting for initial BE length, pre-treatment BE length, hernia status, prior endoscopic mucosal resection (EMR), prior RFA, and prior EMR/RFA sessions, RFA with a focal device at each session remained an independent predictor for a significant reduction in BE extent as compared to the balloon system. CONCLUSION The focal RFA device alone was more effective in treatment of BE compared to the balloon system, with a greater reduction in extent of BE. The focal RFA device for endoscopic eradication therapy of BE should be considered the preferred technique.
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Affiliation(s)
- Jesica Brown
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Benjamin Alsop
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Neil Gupta
- Gastroenterology, Loyola University, USA
| | - Daniel C Buckles
- Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Mojtaba S Olyaee
- Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | | | - Vijay Naag Kanakadandi
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Shreyas Saligram
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
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Strauss AC, Agoston AT, Dulai PS, Srivastava A, Rothstein RI. Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study. Surg Endosc 2015; 28:3366-72. [PMID: 24950726 DOI: 10.1007/s00464-014-3629-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC. METHODS Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications. RESULTS 36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%). CONCLUSION RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.
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Affiliation(s)
- Adam C Strauss
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA,
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27
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Blevins CH, Iyer PG. Endoscopic therapy for Barrett's oesophagus. Best Pract Res Clin Gastroenterol 2015; 29:167-77. [PMID: 25743464 DOI: 10.1016/j.bpg.2014.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/24/2014] [Indexed: 02/06/2023]
Abstract
Barrett's oesophagus (BO) is thought to progress through the development of dysplasia (low grade and high grade) to oesophageal adenocarcinoma, a lethal cancer with poor survival. The overall goal of endoscopic therapy of BO is to eliminate metaplastic and dysplastic epithelium, to prevent and/or reduce the risk of progression to OAC. Endoscopic therapy techniques can be divided into two broad complementary techniques: tissue acquiring (endoscopic mucosal resection and endoscopic submucosal dissection) and ablative. Endoscopic therapy has been established as safe and effective for the subjects with intra-mucosal cancer (IMC), high-grade dysplasia (HGD) and more recently in treating low-grade dysplasia (LGD). Challenges to endoscopic therapy are being recognized, such as incomplete response and recurrence. While eradication of intestinal metaplasia is the immediate goal of endoscopic therapy, surveillance must continue after complete elimination of intestinal metaplasia, to detect and treat recurrences.
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Affiliation(s)
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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28
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Ablative therapy for esophageal dysplasia and early malignancy: focus on RFA. BIOMED RESEARCH INTERNATIONAL 2014; 2014:642063. [PMID: 25140320 PMCID: PMC4129136 DOI: 10.1155/2014/642063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/07/2014] [Indexed: 02/07/2023]
Abstract
Ablative therapies have been utilized with increasing frequency for the treatment of Barrett's esophagus with and without dysplasia. Multiple modalities are available for topical ablation of the esophagus, but radiofrequency ablation (RFA) remains the most commonly used. There have been significant advances in technique since the introduction of RFA. The aim of this paper is to review the indications, techniques, outcomes, and most common complications following esophageal ablation with RFA.
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Abstract
PURPOSE OF REVIEW Several studies published in the last year that have provided evidence on the efficacy, durability and safety of radiofrequency ablation (RFA) in Barrett's esophagus are highlighted in this review. RECENT FINDINGS RFA is well tolerated and efficacious in most but not all Barrett's esophagus patients with dysplasia and esophageal adenocarcinoma (EAC). Recent reports have described highly variable rates of disease recurrence. Disease progression may occur during initial therapy or after complete eradication in a small, difficult to identify subset of patients. Studies are underway to help determine the predictors of response and recurrence. Modifications in technique and target populations have been described in the last year as well. SUMMARY Endoscopic mucosal resection and RFA are the cornerstones in the management of dysplasia and early EAC in Barrett's esophagus patients today. Despite the encouraging data on the effectiveness and safety of RFA, recurrence and progression of disease remain an issue in a subset of patients who are treated.
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Conio M, Fisher DA, Blanchi S, Ruggeri C, Filiberti R, Siersema PD. One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia. Clin Res Hepatol Gastroenterol 2014; 38:81-91. [PMID: 23856637 DOI: 10.1016/j.clinre.2013.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/24/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barrett's esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma. PATIENTS AND METHODS Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture. RESULTS Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent. CONCLUSION One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.
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Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy.
| | - Deborah A Fisher
- Department of Gastroenterology, Durham Veterans Affairs Medical Center and Duke Medical Center, NC, USA
| | - Sabrina Blanchi
- Department of Gastroenterology, General Hospital, Sanremo, Italy
| | | | - Rosa Filiberti
- Epidemiology, Biostatistics and Clinical Trials, IRCCS, San Martino - IST National Institute for Cancer Research, Genova, Italy
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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Aranda-Hernandez J, Cirocco M, Marcon N. Treatment of dysplasia in barrett esophagus. Clin Endosc 2014; 47:55-64. [PMID: 24570884 PMCID: PMC3928493 DOI: 10.5946/ce.2014.47.1.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 12/27/2013] [Accepted: 12/28/2013] [Indexed: 12/20/2022] Open
Abstract
Barrett esophagus is recognized as a risk factor for the development of dysplasia and adenocarcinoma of the esophagus. Cancer is usually diagnosed at an advanced stage with a 5-year survival rate of 15%. Most of these patients present de novo and are not part of a surveillance program. Endoscopic screening with improvement in recognition of early lesions may change this pattern. In the past, patients diagnosed with dysplasia and mucosal cancer were best managed by esophagectomy. Endoscopic techniques such as endoscopic mucosal resection and radiofrequency ablation have resulted in high curative rates and a shift away from esophagectomy. This pathway is supported by the literature review of esophagectomies performed for mucosal disease, as well as pathologists' interpretation of endoscopic mucosal specimens, which document the low risk of lymph node metastasis. The role of endoscopic therapy for superficial submucosal disease continues to be a challenge.
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Affiliation(s)
- Javier Aranda-Hernandez
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Norman Marcon
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
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Falk GW. Update on ablation for Barrett's esophagus. Curr Gastroenterol Rep 2013; 16:368. [PMID: 24357349 DOI: 10.1007/s11894-013-0368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Endoscopic ablation has dramatically changed the treatment algorithm for patients with Barrett's esophagus. Studies clearly show the benefits of this approach for patients with high-grade dysplasia and intramucosal carcinoma. Recent studies also provide evidence in support of this approach for patients with low-grade dysplasia but not for patients with nondysplastic Barrett's epithelium. Endoscopic ablation is safe and efficacious in most but not all patients and disease progression may occur during initial therapy as well as after successful completion in a small difficult to identify subset of patients. Furthermore, the past year has provided us with a better understanding of the durability of endoscopic ablation with highly variable rates of disease recurrence. Studies are underway to help determine predictors of response and recurrence.
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Affiliation(s)
- Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 9 Penn Tower, One Convention Avenue, Philadelphia, PA, 19104, USA,
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Zeki SS, Haidry R, Graham TA, Rodriguez-Justo M, Novelli M, Hoare J, Dunn J, Wright NA, Lovat LB, McDonald SAC. Clonal selection and persistence in dysplastic Barrett's esophagus and intramucosal cancers after failed radiofrequency ablation. Am J Gastroenterol 2013; 108:1584-92. [PMID: 23939625 DOI: 10.1038/ajg.2013.238] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 07/08/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Radiofrequency ablation (RFA) is used to successfully eliminate Barrett's esophagus (BE)-related dysplasia or intramucosal carcinoma and aims to cause reversion to squamous epithelium. However, in 20% of cases RFA fails to return the epithelium to squamous phenotype. Follow-up studies show a similar dysplasia recurrence rate. We hypothesize that failed RFA is due to clonally mutated epithelial populations harbored in RFA-privileged sites and that RFA can select for the mutant clonal expansion. METHODS A longitudinal case series of 19 patients with BE and high-grade dysplasia or intramucosal carcinoma were studied. DNA was extracted from individual Barrett's glands, deep esophageal glands within mucosal resections and biopsy specimens before and after RFA. Mutations were identified by targeted sequencing of genes commonly mutated in Barrett's adenocarcinoma. RESULTS Five patients demonstrated persistent post-RFA pathology with persistent mutations, sometimes detected in deep esophageal glands or neighboring squamous epithelium after several rounds of RFA preceded by mucosal resection. Recurrence of pathology in three other patients was characterized by de novo mutations. CONCLUSIONS Protumorigenic mutations can be found in post-ablation squamous mucosa as well as in mutant deep esophageal glands; both are associated with dysplasia recurrence. Following RFA, non-dysplastic Barrett's epithelium can contain mutant clones that are found in a subsequent adenocarcinoma. Ablation may also drive the clonal expansion of pre-existing clones after a "bottleneck" created by the RFA. Overall, recurrence of dysplasia post RFA reflects the multicentric origins of Barrett's clones and highlights the role of clonal selection in carcinogenesis.
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Affiliation(s)
- Sebastian S Zeki
- Centre for Tumour Biology, Barts Cancer Institute, John Vane Science Centre, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
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Bornschein J, Fitzgerald RC. Barrett's oesophagus: diagnosis, surveillance and treatment. Br J Hosp Med (Lond) 2013; 74:444-50. [PMID: 23958982 DOI: 10.12968/hmed.2013.74.8.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jan Bornschein
- Clinical Research Fellow in the MRC Cancer Cell Unit, Hutchison Research Centre, Cambridge
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Manickam P, Kanaan Z. Postablative stricture formation in ultra-long-segment Barrett's esophagus. Gastrointest Endosc 2013; 78:191. [PMID: 23820415 DOI: 10.1016/j.gie.2013.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 12/11/2022]
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Abstract
INTRODUCTION Barrett's oesophagus (BO) is a common premalignant condition, which carries a risk of progression to oesophageal adenocarcinoma. Recent advances include quantifying the risk of neoplasia progression, novel diagnostic tools and development of new endoscopic techniques to treat early Barrett's cancer. SOURCES OF DATA A selective search was performed on recent advances in BO and this was supplemented with guidelines from the American and British Society of Gastroenterology. AREAS OF AGREEMENT All cases of dysplasia should be confirmed by a second expert histopathologist. Endoscopic therapy is the preferred option for high-grade dysplasia and intra-mucosal (T1a) carcinoma using endomucosal resection (EMR) and/or radiofrequency ablation. EMR also provides accurate staging information and any remaining Barrett segment should be ablated to reduce the risk of metachronous lesions. AREAS OF CONTROVERSY The cell of origin for BO is not certain. The merits and cost effectiveness of endoscopic screening and surveillance still remain controversial. The risk of neoplasia progression in low-grade dysplasia is inconsistently reported. The role of chemoprevention remains unclear. GROWING POINTS The use of radical endotherapy in early Barrett's neoplasia is promising with some data supporting long-term durability. AREAS TIMELY FOR DEVELOPING RESEARCH The development of non-endoscopic diagnostic tools and radical endotherapy to treat early cancer strengthens the argument for surveillance and suggests the possibility of screening in the near future. Identification of a biomarker may help to select high-risk patients.
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Affiliation(s)
- Yean Cheant Lim
- Addenbrooke's Hospital, Hills Road, PO Box 133, Cambridge CB2 0QQ, UK
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